© Department of Continuing Medical Education, Christian Medical College, Vellore
For more information please email: cme@cmcvellore.ac.in

Learning Cases February 2005

STUDY 1: ORTHOPAEDICS - CASE OF THE MONTH

An Infant with a neck swelling

Courtesy: Department of Orthopaedics, CMC, Vellore.

HISTORY



2 weeks old baby with swelling in the left side of the neck.

On examination firm, mildly tender swelling.

1. What is the diagnosis?

   Left sterno mastoid tumour
   
   

2. What does this lead to?

   Torticollis or "Wry neck"
   

3. What is the differential diagnosis for congenital torticollis?

   • Muscular Pathology
   • vertebral anomalies
     • Klippel-feil, occipitalization of C1,
     • Congenital hemiatlas,
     • Combination of the above.
   • Ocular Pathology
   • Neurogenic Pathology

4. What is the natural history of sterno mastoid tumour?

   Fibrosis occur in the muscles and leads to contracture and torticollis. Most of them resolve by 1 year of age with gentle stretching exercises.
   

5. What is the management?

   Gentle stretching exercises for the first year of life. If the conditions does not resolve (10%), surgery may be required.
   

6. What are the associated conditions with this?

   DDH (Developmental dysplasia hip)
   

Acknowledgement: Submitted by Dr. Vrisha Madhuru, Department of Orthopaedics, CMC, Vellore.

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STUDY 2: SURGERY - CASE OF THE MONTH

A lady with a neck swelling

Courtesy: Department of Surgery, CMC, Vellore.

Click on the picture to enlarge.

1. Identify this spotter

   Follicular Carcinoma Thyroid with bony metastasis
   
   

2. What other clinical examination should be done?

   Skeletal survey for other metastasis.
   
   

This patient had multiple bony metastasis all over the body.



3. What are the necessary preoperative investigations?

   FNAC from two sites: Thyroid, Any one bony metastasis. (FNAC revealed follicular cells in both the thyroid and the metastasis.)
   
   Bone scan to look for sites of other bony metastasis
   
   

4. What are the learning points in this case

   Follicular Carcinoma cannot be diagnosed on an FNAC as the diagnosis is made on capsular and vascular invasion which can be made only on biopsy and not an FNAC.
   
   Presence of follicular cells in the thyroid and in the metastasis is enough to confirm the diagnosis of follicular carcinoma
   
   

5. What would be your treatment plan for this patient

   Total thyroidectomy followed by I131 ablation of the metastasis
   
   4-6 sittings of ablative therapy would be required to treat the multiple metastasis.
   
   

Acknowledgement: Submitted by Dr. Deepak Thomas Abraham, Department of Surgery, CMC, Vellore.

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STUDY 3: RADIODIAGNOSIS - X-RAY OF THE MONTH

What's the diagnosis?

Courtesy: Department of Radiodiagnosis, CMC, Vellore.

CASE 1

A young man with pain in the left temporal region. Click on the picture to enlarge.

1. What are the findings in this contrast CT?

   Opacification of left mastoid air cells.
   
   Well defined ring enhancing lesion in the left cerebellar hemisphere with perilesional edema and mass effect on the 4th ventricle.
   
   

2. What is the diagnosis?

   Chronic Suppurative Otitis media with abscess.
   
   

CASE 2

A young man with seizures, vomiting and fever. Click on the picture to enlarge.





3. What are your findings?

   Two thick-walled ring enhancing lesions in the brain stem with perilesional edema with mass effect on the fourth ventricle
   
   Lesions are hypo to iso intense in T2w images.
   
   

4. What is the diagnosis?

   Tuberculosis
   
   




Acknowledgement: Submitted by Dr. Sudheer, Department of Radiodiagnosis, CMC, Vellore.

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